Narrow Results Clear All
- Communication Improvement
- Education and Training 4
- Error Reporting and Analysis 2
- Human Factors Engineering 3
- Legal and Policy Approaches
- Quality Improvement Strategies 3
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 2
- Medication Safety 2
- Surgical Complications 2
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Cases & Commentaries
- Web M&M
D. John Doyle, MD, PhD ; July-August 2005
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Journal Article > Commentary
Anderson P, Townsend T. Amer Nurs Today. March 2010;5:23-27.
This commentary describes 10 elements that contribute to safe medication use and provides suggestions to embed them in daily nursing practice.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.